Incisional Hernia rates between Intracorporeal and Extracorporeal Anastomosis in Minimally Invasive Ileocolic Resection for Crohn's disease

One-third of patients with Crohn’s disease require multiple surgeries during their lifetime, an ileocolic resection most frequently. So, reducing the incisional hernia rate in patients with Crohn’s Disease is crucial. Minimally invasive ileocolic resection with an intracorporeal anastomosis allows using a Pfannenstiel incision as extraction-site, while extracorporeal anastomosis is usually performed with a midline vertical incision. To date, there is limited data regarding incisional hernia after minimally invasive surgery in Crohn’s Disease. To define incisional hernia rates after minimally invasive ileocolic resection for Crohn’s disease, comparing intracorporeal anastomosis with Pfannenstiel incision (ICA-P) versus extracorporeal anastomosis with midline vertical incision (ECA-M). This retrospective cohort of minimally invasive ileocolic resections compares ICA-P versus ECA-M. Data are retrieved from a prospectively maintained database of consecutive minimally invasive ileocolic resections performed between 2014 and 2021 in a referral center for inflammatory bowel diseases specialized in minimally invasive surgery. Exclusion criteria were different extraction-site incision, conversion, and no anastomosis performed. The primary outcome was incisional hernia differentiated between extraction-site incisional hernia (Pfannenstiel or midline vertical incision) and port-site incisional hernia. The incisional hernia was confirmed by imaging with a median follow-up of 15 (4-28) months. Secondary outcomes included 30-day postoperative complications, hospital length of stay, and 30-day readmission. Between 274 patients, 25 were excluded (14 different extraction-site incisions, 8 conversions, 3 no anastomosis). Of the 249 patients included in the analysis: 59 were in the ICA-P group, 190 in the ECA-M group. The surgical approach of the ileocolic resection was 166 (67%) laparoscopic and 83 (33%) robotic. Both groups were similar according to age, sex, BMI, diabetes mellitus, smoking, ASA score, previous surgery, Crohn’s disease preoperative medical treatments, malnutrition, serum laboratory test, preoperative antibiotics, drainage of intra-abdominal collection, nutritional support, associated intraoperative procedures and ventral hernia repair. Overall, 22 (8.8%) patients developed an imaging-proven incisional hernia: seven at the port-site and 15 at the extraction-site. All 15 extraction-site incisional hernias were midline vertical incisions [7.9%; p=0.025], and 8 patients (53%) required surgical repair with mesh placement. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months (p =0.037). Port-site incisional hernia rate was similar between the two groups, all were < 20mm, contained preperitoneal fat tissue, and none underwent surgical repair. The overall 30-day postoperative complication rate was 28.1% [ICA-P: 11 (18.6) vs. ECA-M: 59 (31.1); p=0.064], and severe complications (Clavien-Dindo classification ≥ 3) occurred in 16 (6.4%) patients. The length of stay was lower in the ICA-P group [ICA-P: 3.3±2.5 vs. ECA-M: 4.1±2.4 days; p=0.02] with similar 30-day readmission rates [ICA-P: 7 (11.9) vs. ECA-M: 18 (9.5); p=0.59]. Patients in the ICA-P group did not encounter any incisional hernias while having shorter hospital length of stay and similar 30-day postoperative complications or readmission compared to ECA-M. Time-to-event analysis showed a 20% rate of extraction-site incisional hernia in the ECA-M group after 48 months. Therefore, strong consideration should be given to performing intracorporeal anastomosis with Pfannenstiel incision during Ileocolic resection in patients with Crohn’s to reduce hernia risk.